Is there such thing as idiopathic NEAD?

Is there such thing as idiopathic NEAD?

Dr Jenny TaylorDr Sumeet Singhal Dr Roshan das Nair

Dr Patrick Vesey

“Nothing bad’s ever happened to me”

Aims Background and rationaleMethodsResultsDiscussion pointsConclusionsClinical ImplicationsQuestions

Psychogenic non-epileptic seizuresPsychogenic non-epileptic seizures

(PNES) resemble epileptic seizures, but no abnormal electrical changes in the brain (Bodde, et al., 2009)

Incidence: 25-30% of those referred to epilepsy centres (Bodde, et al., 2009)

Accepted to be psychological in nature (Lesser, 1996)

Higher rates of psychological problems and trauma history (review: Reuber, 2008)

Always psychological causality? Maybe not...

Absence of psychological comorbidity or trauma history in 3 – 32% of people with PNES (Moore & Baker, 1997; Reuber, et al., 2007; Marchetti, et al., 2008)

None of these studies examined the presenting profiles of those without causal factors

Why not always causal factors?1. Absence of trauma/psychological comorbidity?

2. Non-expression?

a) Methodological factors, e.g. Underreporting in interviews (Fiszman, et al., 2004)

b) Other, e.g. Personality factors

Key aim of the current study

Why is this important?Treatment of choice is psychological (National Collaborating Centre

for Primary Care : Stokes, et al., 2004)

Treatment assumes psychological problems/trauma historyInvalidating?

Ineffective?

Methods: ParticipantsPatients diagnosed with PNES by neurologist

PNES-trauma (PNES-T): Those reporting trauma history/psychological comorbidity N = 10

PNES-no-trauma (PNES-NT): Those not reporting the above N = 9

T = Trauma NT = No-trauma

Methods: Measures & Analysis


MeasuresTraumatic Life Events Questionnaire (TLEQ)Trauma Symptom Inventory (TSI)Millon Clinical Multiaxial Inventory III (MCMI-III)

AnalysisMann-Whitney U-Tests (between-group differences)Cohen’s d effect sizes (between-group effect sizes) ROC curve analysis (evaluation of classification system)Chi-squared test (gender comparison)

Traumatic Life Events Questionnaire (TLEQ)Kubany et. al (1995)


1. Natural disaster2. Motor vehicle accident3. Other kind of accident4. Lived/worked/military service in a war zone and exposed to warfare/combat5. Experienced sudden and unexpected death of a close friend/loved one6. Loved one survived life-threatening accident/assault/illness7. Had a life-threatening illness8. Been robbed/present during robbery involving a weapon9. Hit/beaten up and badly hurt by a stranger10. Seen a stranger attack/beat up someone, leading to serious injury/death11. Threats to kill/seriously harm you

Traumatic Life Events Questionnaire (TLEQ)Kubany et. al (1995)


12. Physical abuse whilst growing up13. Witness to domestic violence whilst growing up14. Subject to domestic violence 15. Sexual abuse from an adult when under 1316. Sexual abuse from a peer when under 1317. Sexual abuse when aged 13-1818. Sexual assault when 18+19. Other unwanted sexual attention20. Victim of stalking21. Miscarriage 22. Abortion23. Any other events

Results: Demographics


Group

P valueT (n=10) NT (n=9)

Gender 2 M; 8 F (80% F) 3 M; 6 F (67% F) .51

Age: Mean (SD) 40.7 (10.80) 33.67 (9.26) .13

Time since onset, months: Mean (SD)

77.78 (73.55) 91.89 (65.64) .34

Time since diagnosis, months: Mean (SD)

19.8 (10.83) 27.44 (22.33) .72

Time to diagnosis from onset, months: Mean (SD)

56.67 (72.76)= 4.7 years

62.56 (67.60)= 5.2 years

.67

Results: Traumatic Life Events Questionnaire


Between-group differencesTotal number of events experienced:

Median (IQR); T = 6.5 (3); NT = 2 (1)Significantly more events in T group (p=0.007; ES=1.00)

Amount of distress for most distressing experience:Median (IQR); T = 4.5 (3); NT = 2 (2.5)Difference not statistically significant (p=0.210; ES=0.67)

Results: Traumatic Life Events Questionnaire


Comparison with general populationT group: Higher rates of reporting in 14/23 life events:

Childhood physical abuse, miscarriage, motor vehicle accidents, sudden death of a friend or loved one, assault, threat of harm, witness to family violence, intimate partner abuse, sexual abuse across the lifespan , sexual harassment, and stalking.

NT group: Higher rates of reporting in only 2/23 life eventsChildhood physical abuse & Miscarriage

Results: Trauma Symptom Inventory


Between-group differencesSignificantly higher levels in T group than NT group on

the following scales:Anger/Irritability (p=0.008; ES=1.18)

Intrusive experiences (p=0.004; ES=1.25)

Defensive avoidance (p=0.001; ES=1.59)

Sexual concerns (p=0.040; ES=0.86)

Tension reduction behaviour (p=0.040; ES=0.86)

Results: Trauma Symptom Inventory


Comparison with general populationT group: Scored higher on all 11 subscales

NT group: Scored higher on only 3/11 subscales:Sexual concerns, Dysfunctional sexual behaviour and

Tension reduction behaviour

Results: Millon Clinical Multiaxial Inventory–III


Between-group differences: Modifying Indices

Significantly higher levels of Debasement (tendency to describe oneself in pathological terms) in the T group (p=0.050; ES=0.90)

Significantly lower levels of Disclosure (tendency towards being defensive and secretive in their answering) in the NT group (p=0.014; ES=1.18)



Between-group differences: Clinical & Personality ScalesSignificantly higher scores in the T than the NT group on the

following scales: Personality Patterns (Axis II disorders):

Depressive (p=0.006; ES=1.21)

Sadistic/Aggressive (p=0.003; ES=1.31)

Masochistic/Self-defeating (p=0.050; ES=0.99)

Clinical Syndromes (Axis I disorders):Anxiety (p=0.006; ES=1.26)

PTSD (p=0.002; ES=1.43)

NB however: levels of

Disclosure and Debasement



Comparison with general populationT group:

Modifying indices: Higher Disclosure and Debasement; lower Desirability

Clinical/Personality scales: Higher on 8/18 scales (Avoidant, Depressive, Dependent, Negativistic/ Passive-Aggressive, Masochistic/Self-Defeating, Anxiety, Dysthymia, PTSD); PLUS 3/3 Severe Personality Pathology, 3/3 Severe Clinical Syndrome scalesLower on Histrionic and Narcissistic

NT group:Modifying indices:

Higher Debasement; similar Disclosure and Desirability Clinical/Personality scales:

Higher on Somatoform, Thought Disorder and Major Depression

Results: ROC curve analysis


Conducted for TLEQ to evaluate consistency of neurologist classification system with TLEQ

Based on analysis:>4.5 life events T group<4.5 life events NT group

16 out of 19 participants (84.2%) were classified in the same way by both the neurologist and the questionnaire data

Summary of results


T group reported twice as many traumatic life events as NT group and a trend to more distress (ns)

T group reported greater Axis I and II pathology than NT group

T group reported more trauma and psychological pathology than the general population

NT group similar to general population

Discussion: Why the differences?


1. Truly idiopathic NEAD group?

2. Clinical questioning nor questionnaires sufficiently sensitive?

3. NT group misdiagnosed as NEAD?

4. T group over-exaggerating experiences as traumatic and over-exaggerating psychological comorbidity?

5. NT group under-reporting?

Conclusions


Group differences remained following structured and more anonymous questioning

Supports ‘different’ groups, and NEAD causes being more heterogenous than previously suspected

However, if proven, the Disclosure differences could explain why groups appear different, but are not

Þ Worthy of sufficiently powered formal study

Clinical ImplicationsUtility of self-report measures

Possible limitations of self-report measures (disclosure?)

Utility of individual psychological formulation


Questions?


References (1)Bodde, N. M., Brooks, J. L., Baker, G. A., Boon, P. A., Hendriksen, J. G., Mulder,

O. G., et al. (2009). Psychogenic non-epileptic seizures--definition, etiology, treatment and prognostic issues: a critical review. Seizure, 18(8), 543-553.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101.

Briere, J. (1995). Trauma symptom inventory. Odessa, FL: Psychological Assessment Resources.

Brown, R. J. (2004). Psychological mechanisms of medically unexplained symptoms: an integrative conceptual model. Psychological Bulletin, 130(5), 793-812.

Coolican, H. (2009). Research Methods and Statistics in Psychology (5th ed.). London: Hodder Education.

References (2)Fiszman, A., Alves-Leon, S. V., Nunes, R. G., D'Andrea, I., & Figueira, I. (2004).

Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review. Epilepsy Behav, 5(6), 818-825.

Howlett, S., Grunewald, R. A., Khan, A., & Reuber, M. (2007). Engagement in psychological treatment for functional neurological symptoms - Barriers and solutions. Psychotherapy, 44(3), 354-360.

Kubany, E. S. (1995). The Traumatic Life Events Questionnaire (TLEQ): A brief measure of prior trauma exposure. Unpublished scale. Available from the author.

Lesser, R. P. (1996). Psychogenic seizures. Neurology, 46(6), 1499-1507.

Marchetti, R. L., Kurcgant, D., Neto, J. G., von Bismark, M. A., Marchetti, L. B., & Fiore, L. A. (2008). Psychiatric diagnoses of patients with psychogenic non-epileptic seizures. Seizure, 17(3), 247-253.

References (3)Millon, T., & Davis, R. (1996). The Millon Clinical Multiaxial Inventory-Ill. Major

Psychological Assessment Instruments, 108.

Moore, P. M., & Baker, G. A. (1997). Non-epileptic attack disorder: a psychological perspective. Seizure, 6(6), 429-434.

Reuber, M. (2008). Psychogenic nonepileptic seizures: answers and questions. Epilepsy & Behaviour, 12(4), 622-635.

Reuber, M., Howlett, S., Khan, A., & Grunewald, R. A. (2007). Non-epileptic seizures and other functional neurological symptoms: Predisposing, precipitating, and perpetuating factors. Psychosomatics: Journal of Consultation Liaison Psychiatry, 48(3), 230-238.

Stokes, T., Shaw, E. J., Juarez-Garcia, A., Camosso-Stefinovic, J., & Baker, R. (2004). Clinical Guidelines and Evidence Review for the Epilepsies: diagnosis and management in adults and children in primary and secondary care. London: Royal College of General Practitioners.

Is there such thing as idiopathic NEAD?

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